Psychiatric records: variations based on discipline and patient characteristics, with implications for quality of care

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Abstract
In this study of the delivery of outpatient psychiatric care to Medicaid patients at all 29 free-standing psychiatric clinics and at six hospital clinics in New York City, the authors found that nonphysician mental health workers provided much direct patient care: diagnosis and identifying data, necessary for reimbursement, were always included in records whereas mental status and medical history were poorly documented; and nonphysicians in hospitals generally surpassed physicians in the latter two areas. An additional observation was that attitudes of mental health workers toward certain diagnostic and ethnic groups may be inferred from the selective completeness of their psychiatric record keeping.